GENERAL PHENOMENA OF MENSTRUATION. Changes at Puberty.-At this period of life, when the girl becomes the woman, we find certain well marked general changes occurring The bust and mons veneris develope and the whole contour of the body becomes more rounded and attractive; hair appears on the genitals. The romping carriage of the girl becomes subdued, and greater shyness characterises her conduct to the opposite sex. Phenomena premonitory to each menstrual flow.-There is usually a feeling of weight in the pelvis and increase of sexual inclination. Many women, however, have very little uneasiness during the whole flow; while others are always considerably distressed,-this distress being still outside the boundary of actual disease. Periodicity and duration of Discharge. When once established it recurs with great regularity every 28 days (in -71 p. c.), 30 days (in - 14 p. c.), 21 days (in – 12 p. c.), or 27 days (in + 1 p. c.). We speak therefore of the 21 day type and so on. It lasts for a number of days, varying from 2 to 8. If below 2 or above 8 it is abnormal; but of course other points besides mere duration must be taken into account. LOCAL PHENOMENA. Three periods are distinguished; 1. Invasion, 2. Persistence, 1. Invasion.-Discharge pale. 2. Persistence.-Discharge bright red, non-coagulable from its admixture with mucus. It consists microscopically of epithelium from vaginal, cervical, and uterine cavities; mucous globules; compound granular corpuscles, and red and white blood corpuscles. 3. Decline.-Discharge lessens in amount and becomes lighter in colour. The total quantity varies from 2 to 8 ounces. Thus far we have related facts fairly well ascertained and not much disputed. We now enter on more debateable ground, in considering— I. Ovulation; II. The Corpus luteum; III. Source of discharge, and changes in the uterine mucous membrane. I. Ovulation. So far as our present knowledge goes, ovulation forms the starting point of the process of menstruation. We have already considered the structure and development of the ovary, and now describe The changes in the Ovary at each Menstrual Period.-A graafian follicle enlarges and moves nearer the surface. Probably this produces through a nervous mechanism, a hyperæmia of the whole pelvic contents,-peritoneum, connective tissue, uterus, ovaries, Fallopian tubes, and vagina. It is alleged, as yet on insufficient grounds, that the fimbriated end of the Fallopian tube grasps the Ovary and that the ovum from the ruptured graafian follicle passes into it and along the tube to the uterine cavity. Professor Kinkead of Galway has recently advanced another explanation. He points out that, between the fimbriated end of the Fallopian tube and the ovary, we have the ovarian fimbria (fig. 22) forming a groove which is converted into a tube by the surrounding viscera; and that consequently we have capillary action towards the uterus. This will lead the ovum into the Fallopian tube. However it may reach the Fallopian tube and uterus, its further development depends on its fertilization or non-fertilization. In the latter case it passes off unnoticed in the menstrual discharge; in the former it developes into the fœtus. II. The Corpus luteum.-After the rupture of the graafian follicle, we get its cavity filled up by the structure known as the corpus luteum. The corpus luteum consists of a vascular framework, with a yellow pigmentary and cellular substance. It varies according as pregnancy The difference is well given in does or does not follow its formation. Dalton's table, which we subjoin. III. Source of Discharge and Changes in the Uterine Mucous Membrane.-All observers are agreed that the mucous membrane of the uterine cavity is the source of the discharge, i.., that it comes from the area limited by the uterine ends of the Fallopian tube and the os internum. Now begins the divergence. (1.) Williams holds that "uterine contraction drives the blood from the muscular wall into the mucous membrane; the vessels of this membrane, having undergone fatty degeneration, give way, and extravasation of blood results. This extravasation takes place always near the surface, for in that situation the degenerative change has most advanced. The rush of blood into the vessels of the mucous membrane expels the contents of the glands, together with the greater part of their lining epithelium. . . . When hæmorrhage has taken place into the membrane, it undergoes rapid disintegration, and becomes entirely removed. ... The new mucous membrane "is produced by proliferation of the Fig. 68. Diagram of Uterus just before menstruation. The shaded portion represents the mucous membrane (J. Williams). Fig. 69. Diagram of Uterus when menstruation has just ceased, showing the cavity of the body deprived of mucous membrane (J. Williams). elements of the muscular wall of the organ, the muscular fibres producing the fusiform cells, the connective tissue, the round cells, and the groups of round cells in the meshes formed by the muscular bundles, the glandular epithelium." Entire removal of the mucous membrane and its regeneration from the muscular coat, are the essentials of Williams' views. (2.) Kundrat and Engelmann describe the change at the menstrual period as follows: Mucous membrane becomes swollen and pulpy, and measures in thickness 3-6 mm. The thickness is most marked at the fundus and Fig. 70. Mucous Membrane of menstruating uterus (, Kundrat and Engelmann). The surface is central portions of the anterior and posterior surfaces. puffy and injected; glands are distinctly seen on section as fine spirals. Microscopically, this increase in thickness is seen to be due to a proliferation of the round cells of the stroma, an enlargement of all the cell elements in the superficial layers, and an increase of the intercellular substance. This superficial layer has grown far above the original gland openings, causing the funnel-shaped depressions or small pits seen on surface view. The glands are increased in thickness and length. The vessels are enlarged and gorged with blood. Fig. 70 shows the mucous membrane of the menstruating uterus magnified 40 times; it should be compared with the mucous membrane of the non-menstruating uterus at fig. 19, also magnified 40 times. The increase of the thickness of the mucous membrane begins as the time of menstruation approaches, is most marked during the period itself, and gradually decreases after the cessation of the catamenial flow. Fatty degeneration takes place in the cells of the interglandular tissue, blood vessels, and glandular and surface epithelium. They hold that "the hæmorrhage is always confined to the surface of the lining membrane, and is due to the fattily degenerated tissue being unable to resist the blood pressure;" and they therefore maintain, what is most probably the case, that only the superficial layer of the mucous membrane is shed at a menstrual period. (3.) Leopold denies the existence of any fatty degeneration of the superficial layers of the mucous membrane. He believes that an extravasation of red and white blood corpuscles from the superficial capillaries takes place especially towards the superficial layer, undermining the uppermost layer of cells; and that, finally, the copious supply of blood reaching these capillaries from the numerous arteries causes rupture and bleeding. The mucous membrane is regenerated by an upward growth of the glandular epithelium. Williams, Kundrat, Engelmann, and Leopold examined uteri from post-mortem cases. Recently Möricke has curetted the uteri of living women at various stages of their menstruation, and microscopically examined what he removed. He asserts that "during menstruation the mucous membrane disappears neither partially nor fully." This shows how widely microscopists vary. Williams says all the mucous membrane is removed; Kundrat, Engelmann, and Leopold say only the superficial layers are removed; and Möricke says none is removed. We have deemed it best to lay these views before the student. The subject is difficult to investigate, and one on which the authors are not qualified to give an opinion. They incline, however, to the views of Kundrat, Engelmann, and Leopold. The chief difficulty in regard to Williams' view is the regeneration of the new mucous membrane from the muscular coat. Finally, it should be noted that almost all observers consider ovula |